A STUDY ON
THE PREOPERATIVE PREDICTION OF A DIFFICULT
LAPAROSCOPIC CHOLECYSTECTOMY
A DISSERTATION SUBMITTED TO
THE TAMILNADU DR.M.G.R MEDICAL UNIVERSITY
In partial fulfillment of the regulations for the award of the
Degree of M.S., (GENERAL SURGERY)
BRANCH – I
DEPARTMENT OF GENERAL SURGERY
STANLEY MEDICAL COLLEGE AND HOSPITAL
THE TAMILNADU DR.M.G.R MEDICAL UNIVERSITY
CHENNAI
APRIL 2014
CERTIFICATE
This is to certify that the dissertation entitled
“A STUDY ON THE PREOPERATIVE PREDICTION OF A
DIFFICULT LAPAROSCOPIC CHOLECYSTECTOMY” is the
bonafide work done by Dr. G. SOUNDARYA, Post Graduate student
in the Department of General Surgery, Government Stanley
Medical College and Hospital, Chennai, 2011- 2014 under my direct
guidance and supervision, in partial fulfillment of the regulations of
The Tamil Nadu Dr. M.G.R Medical University, Chennai for the
award of M.S., Degree (General Surgery) Branch - I, Examination
to be held in April 2014.
Prof. A. RAJENDRAN, M.S., Prof. K. KAMARAJ, M.S.,Professor , Professor and Head , Dept. of General Surgery, Dept. of General Surgery, Stanley Medical College, Stanley Medical College ,Chennai-600001. Chennai-600001.
PROF. S. GEETHA LAKSHMI, M.D., PhD,The Dean,
Stanley Medical College,
Chennai-600001.
DECLARATION
I, Dr. G.SOUNDARYA, solemnly declare that this dissertation
titled “A STUDY ON THE PREOPERATIVE PREDICTION OF A
DIFFICULT LAPAROSCOPIC CHOLECYSTECTOMY” is a
bonafide work done by me in the Department of General Surgery,
Government Stanley Medical College and Hospital, Chennai, under the
guidance and supervision of my unit chief, Prof. A. RAJENDRAN,
M.S., and the Head of my Department, Prof. K. KAMARAJ, M.S.
This dissertation is submitted to The Tamilnadu Dr. M.G.R.
Medical University, Chennai in partial fulfillment of the university
regulations for the award of M.S., Degree (General Surgery) Branch-I,
Examination to be held in April 2014.
Place: Chennai.
Date: December 2013. DR. G.SOUNDARYA.
ACKNOWLEDGEMENT
I am deeply indebted to my guide Prof. A. Rajendran, Professor
of Surgery for his support, encouragement and valuable advice which
has brought out the best in me.
I owe a lot to my Assistant Professors Dr. P. Balaji,
Dr. G. V. Manoharan, Dr. G. Venkatesh ,Dr. G. Vignesh and
Dr. Jim Jebakumar for their constant guidance and inspiration
without which the study could not have been possible.
I consider it a privilege to have done this study under the
supervision of my beloved Professor and Head of the Department
Prof. K. Kamaraj, who has been a constant source of support.
I express my sincere gratitude to my mentor
Prof. S. Deivanayagam, former Head of the Department of General
Surgery for his inspiring words and able guidance which remained a
constant support throughout my course and I am extremely thankful to
him.
I am grateful to the Dean Prof. S. Geethalakshmi for permitting
me to conduct the study and use the resources of the College.
It is my earnest duty to thank my parents without whom
accomplishing this task would have been impossible.
I am extremely thankful to my patients who consented and
participated to make this study possible.
CONTENTS
S. NO. CHAPTER PAGE NO
1. INTRODUCTION 1
2. REVIEW OF LITERATURE 4
3. AIMS AND ODJECTIVES 54
4. MATERIALS & METHODS 55
5. OBSERVATION AND RESULTS 60
6. DISCUSSION 71
7. CONCLUSION 77
8. BIBLIOGRAPHY
9. ANNEXURE
(i) PROFORMA
(ii) INSTITUTIONAL ETHICAL
COMMITTEE APPROVAL
CERTIFICATE
(iii) MASTER CHART
(iv) TURNITIN SCREEN SHOT
(v) PATIENT INFORMATION
SHEET
(vi) CONSENT FORM
ABSTRACT
A STUDY ON THE PREOPERATIVE PREDICTION OF A DIFFICULT
LAPAROSCOPIC CHOLECYSTECTOMY
Introduction
Laparoscopic cholecystectomy has become the standard operative procedure for
cholelithiasis, but there are still some patients requiring conversion to open
cholecystectomy mainly because of technical difficulty. The aim was to define the
possibility of prediction of a difficult outcome preoperatively.
Materials and Methodology
40 patients with symptomatic gallstones planned for elective surgery and operated
upon by a single experienced laparoscopic surgeon were studied by assigning a
score depending upon clinical and sonological parameters.
Results
Out of 40 cases, 11 had a difficult outcome with scores ranging between 5 and 10.
None had a score >10. Age >50, Obesity, Previous hospitalization, Palpable
gallbladder and Wall thickness > 4mm on ultrasonogram were found to
significantly influence the outcome. The ideal cut off point was a score of 3, which
could predict difficulty. Overall the positive predictive value was 78.57%.
Conclusion
A difficult laparoscopic cholecystectomy can be predicted preoperatively. Patients
having high risk may be informed and scheduled appropriately. An experienced
surgeon has to operate on these patients, and he or she has to make an early
decision to convert in case of difficulty
Keywords
Laparoscopic cholecystectomy, prediction, risk factors.
INTRODUCTION
Biliary tract surgeries are amongst the most commonly performed
ones in the abdomen.
Open cholecystectomy (OC), ever since described by Carl
Langenbuch in 1882, has been the prime modality of treating gallstone
disease for about a century.
The introduction of Laparoscopic cholecystectomy (LC) in 1985,
by Mühe of Böblingen, Germany has revolutionised the treatment of
gallstones. Having been recognised as the "gold standard" for treating
gallstone disease, this has supplanted open cholecystectomy, and also
ended attempts towards noninvasive management like extracorporeal
shock wave lithotripsy and bile salt therapy.
In 1992, the National Institutes of Health (NIH) Consensus
Development Conference stated that LC provides a safe and effective
treatment for most patients with symptomatic gallstones.
The advantages of LC over OC are immediately appreciated;
earlier return of bowel function, less postoperative pain, improved
cosmesis, shorter hospital stay, earlier return to normal activity and
decreased overall cost. Currently it is estimated that 90% of
cholecystectomies are performed by the laparoscopic approach. Indeed,
LC as a mature mode of therapy has introduced the general surgical
world to the advantages and unique perspectives of minimal access
surgery.
Despite the charm of endoscopic surgery, the slightly higher rate
of certain complications associated with laparoscopic surgery as
compared to the open one, remains a setback and is a cause of
scepticism among the general public.
Therefore it would be worthwhile to evaluate the possibilities of
predicting the chances of a difficult laparoscopic cholecystectomy,
which would ensure safety to the patient and also avoid litigation.
There have been many attempts to this approach and various
parameters, clinical and radiological have been analysed and many
scoring systems developed. The answer is an emphatic yes, when it
comes to the question of whether a difficulty could be predicted
preoperatively.
An ideal system should encompass factors proven to have an
influence on the outcome, should include investigations at an optimum
cost, and the prediction should be individualised based on clinical
judgement.
Much more than the score itself, it is the impact of certain factors
which would ultimately determine the outcome.
The preoperative prediction aims at patient counselling and also
guiding the surgeon to decide on an early conversion, should difficulty
arise and also involve an experienced surgeon in the task and thereby
ensure patient safety.
REVIEW OF LITERATURE
HISTORY OF THE GALL BLADDER AND GALLSTONES
The earliest known gall stones were found in the mummy of a
Priestess of Arnan (1085-945 BC) by the Egyptians.
Galen (138-201AD) described the storage function of the gall
bladder.
Gallstones were first described in the fifth century, by a Greek
physician named Alexander Trallianus (525-605 BC). The first clinical
description of the gallstone disease was given by Gordon Taylor as early
as the 4th century BC [1].
Francis Glisson (1597-1677), an English anatomist believed
that there must be some substance in fresh grass which dissolves
gallstones.He noted that gallstones were seen in the intestines of oxen
after eating winter hay and straw, but not after grazing.
Jean-Louis Petit was the first person to remove gallstones by
draining the gallbladder in 1743, and from then onwards he was called
the founder of gallbladder surgery.
Dr. John Stough Bobbs (1809 to 1870), a Civil War surgeon from
Pennsylvania, is credited with the first cholecystostomy in 1867.To him,
“The museum of surgical art is an operation theatre.
Carl Johann August Langenbuch [2] of Berlin (1846to 1901)
performed the first cholecystectomy on July 15, 1882.His principle was,
“the gallbladder needs to be removed, not because it contains stones, but
because it forms them”.
Bernard Naunyn in 1892 made remarkable achievements by
describing the physiological basis behind gall stone formation. He stated
that gallbladder stasis contributed greatly to gallstone formation on the
nidus originating from sloughed out epithelial cells and other debris. He
also recognised Escherichia coli and Salmonella typhi causing
cholecystitis and cholangitis as contributing factors [1, 3].
On September 12, 1985 (103 years later after the description of
open approach), Prof. Erich Mühe of Germany performed the first
laparoscopic cholecystectomy (LC) [4].
ANATOMY
A. Embryology
The caudal region of the foregut gives rise to what is called the
hepatic diverticulum during the 4
hepatic diverticulum gives rise to
Gall bladder develops from the latter, while the former develops into
liver and extrahepatic biliary radicals and they luminise by 8
intrauterine life.
Figure
B. HISTOLOGY
The gallbladder wall consists of five layers,
i) columnar epithelium
ii) lamina propria,
The caudal region of the foregut gives rise to what is called the
hepatic diverticulum during the 4th week of intrauterine life
gives rise to the pars hepatica and pars cystica
Gall bladder develops from the latter, while the former develops into
liver and extrahepatic biliary radicals and they luminise by 8th
Figure 1. Embryology of Gall Bladder
er wall consists of five layers,
columnar epithelium
propria,
The caudal region of the foregut gives rise to what is called the
week of intrauterine life [5].The
the pars hepatica and pars cystica.
Gall bladder develops from the latter, while the former develops into
th week of
iii) smooth muscle – with ganglia in between the smooth
muscle bundles
iv) subserosal connective tissue, and
v) serosa.
The gallbladder lacks submucosa[6,7]. Rokitansky-Aschoff
sinuses are the invaginations of epithelium into the lamina propria,
muscle, and subserosal connective tissue [6, 7]. They are present in
about 40% of normal gallbladders and in abundance in most inflamed
gallbladders.
The ducts of Luschka are tiny bile ducts that are found around
the muscle layer on the hepatic side of the gallbladder, in about 10% of
normal gallbladders. They have no relation to the Rokitansky-Aschoff
sinuses or to cholecystitis.
C.GROSS ANATOMY:
The gallbladder, a pear-shaped organ lies on the inferior surface
of the liver at the junction of the left and right hepatic lobes between
Couinaud's segments IV and V.
The gallbladder ranges from 7 to 10 cm in length and from 2.5 to
3.5 cm in width. The gallbladder's volume varies considerably between
fasting states and after a meal. A moderate gallbladder has a capacity of
50 to 60 ml.
The gallbladder has been divided into four areas: the fundus,
body, infundibulum, and neck. The Hartmann's pouch is an
asymmetrical bulge of the infundibulum which lies close to the
gallbladder's neck.
The cystic duct arises from the gallbladder, courses downward in
the hepatoduodenal ligament and joins the lateral aspect of the
supraduodenal portion of the common hepatic duct at an acute angle to
form the common bile duct. The length of the cystic duct varies between
2 and 4 cm [6,7].
The Triangle Of Calot and The Hepatocystic Triangle Of Moosman:
Jean Francois Calot in 1891
cystic artery as the superior border,
border and cystic duct
the other hand has its upper boundary formed b
Figure 2. Biliary Anatomy
Calot and The Hepatocystic Triangle Of Moosman:
Jean Francois Calot in 1891 described a triangular region having
cystic artery as the superior border, common hepatic duct as the medial
as the lateral border [8]. Moosman’s triangle on
the other hand has its upper boundary formed by liver [6, 7].
Calot and The Hepatocystic Triangle Of Moosman:
region having
as the medial
. Moosman’s triangle on
An aberrant right hepatic artery arising from the superior
mesenteric artery may course through the medial aspect of the triangle,
posterior to the cystic duct. A
triangle is essential while perfo
ARTERIAL SUPPLY AND VENOUS DRAINAGE:
Cystic artery arises from right hepatic artery and supplies the
gallbladder. Rarely, it may also arise from the common hepatic, left
hepatic or gastroduodenal artery
predominantly, while some portions, especially the superior surface
Figure 3.Calot's triangle
An aberrant right hepatic artery arising from the superior
mesenteric artery may course through the medial aspect of the triangle,
posterior to the cystic duct. A clear visualization of the hepatocystic
while performing a cholecystectomy.
ARTERIAL SUPPLY AND VENOUS DRAINAGE:
arises from right hepatic artery and supplies the
gallbladder. Rarely, it may also arise from the common hepatic, left
hepatic or gastroduodenal artery. Venous drainage is by cystic veins
predominantly, while some portions, especially the superior surface
An aberrant right hepatic artery arising from the superior
mesenteric artery may course through the medial aspect of the triangle,
clear visualization of the hepatocystic
arises from right hepatic artery and supplies the
gallbladder. Rarely, it may also arise from the common hepatic, left
Venous drainage is by cystic veins
predominantly, while some portions, especially the superior surface
drain directly into hepatic veins. Occasionally, the cystic vein may drain
into the right branch of portal vein [6].
NERVE SUPPLY:
The gallbladder and biliary tree receive sympathetic and
parasympathetic nerve fibres from the celiac plexus. Parasympathetic is
by way of the hepatic branch of the left (anterior) vagal trunk.
Sympathetic fibres arising from the 5th to the 9th thoracic segments
pass through the greater splanchnic nerves to the celiac ganglion.
Postganglionic sympathetic fibres accompany the hepatic artery to
innervate the gallbladder, bile duct and liver [10].
Sensory fibres from the right phrenic nerve, through
communications between the phrenic plexus and the celiac plexus also
innervate the gallbladder, which explains the phenomenon of referred
shoulder pain in patients with gallbladder disease.
Figure
ANOMALIES
A) Cystic duct
The anomalies of cystic duct which are important during a
cholecystectomy were described by Benson and Page in 1976. The
cystic duct may run parallel to the common hepatic duct for a variable
distance (15%), or it may spiral anterior or posterior to the co
hepatic duct to form a left
The cystic duct may join the right hepatic duct or a right
segmental duct. Occasionally, the gallbladder may join the common
hepatic duct with a short or virtually nonexistent cystic duct. During
Figure 4. Innervation of the Gallbladder
The anomalies of cystic duct which are important during a
cholecystectomy were described by Benson and Page in 1976. The
cystic duct may run parallel to the common hepatic duct for a variable
distance (15%), or it may spiral anterior or posterior to the co
hepatic duct to form a left-sided union (8%).
The cystic duct may join the right hepatic duct or a right
segmental duct. Occasionally, the gallbladder may join the common
hepatic duct with a short or virtually nonexistent cystic duct. During
The anomalies of cystic duct which are important during a
cholecystectomy were described by Benson and Page in 1976. The
cystic duct may run parallel to the common hepatic duct for a variable
distance (15%), or it may spiral anterior or posterior to the common
The cystic duct may join the right hepatic duct or a right
segmental duct. Occasionally, the gallbladder may join the common
hepatic duct with a short or virtually nonexistent cystic duct. During
ligation of a short cystic duct, care must be taken not to compromise the
lumen of the common bile duct. [9]
Figure
B) Gall Bladder
Formation
a. Phrygian cap
b. Bilobed gallbladder
c. Hourglass gallbladder
d. Diverticulum of
e. Rudimentary gallbladder
of a short cystic duct, care must be taken not to compromise the
lumen of the common bile duct. [9]
Figure 5. Cystic duct anomalies
Phrygian cap
Bilobed gallbladder
Hourglass gallbladder
Diverticulum of the gallbladder
Rudimentary gallbladder
of a short cystic duct, care must be taken not to compromise the
Number
a. Absence of the gallbladder (agenesis)
b. Duplication of the gallbladder
Position
a. Floating gallbladder
b. Intrahepatic gallbladder
c. Left-sided gallbladder
d. Transverse gallbladder
e. Retrodisplaced gallbladder [8]
Phrygian Cap
This is the most common anomaly of the gallbladder in which the
deformity is created by an infolding of a septum between the body and
the fundus. It is found more commonly in women. Boyden identified
this anomaly in 18% of patients with a normally functioning gallbladder
and is not an indication for cholecystectomy.
Figure
Figure
Bilobed Gallbladder
This occurs in two forms
longitudinal fibrous septum, the other type appears like two separate
gallbladders fused at the neck. It has no clinical importance.
Figure 6. Phrygian cap
Figure 7. Hour glass Gall Bladder
Figure 8. Bilobed Gallbladder
his occurs in two forms-one that is divided internally
longitudinal fibrous septum, the other type appears like two separate
gallbladders fused at the neck. It has no clinical importance.
one that is divided internally by a
longitudinal fibrous septum, the other type appears like two separate
Hourglass Gallbladder
This occurs as a congenital anomaly in children whereas in adults,
it usually occurs as a result of chronic cholecystitis. The latter type,
though not the former, requires removal.
Diverticulum of the Gallbladder
Congenital diverticula vary between 0.5 – 9cm and can arise from
any part of the gallbladder. They assume significance when they contain
stones, become inflamed, or perforate. On the contrary, Hartmann's
pouch is an acquired diverticulum which occurs at the infundibulum or
neck of the gallbladder in conditions of chronic obstruction to emptying.
Absence of the Gallbladder (Agenesis)
Around 200 cases have been reported so far. Most patients die
within 6 months after birth owing to other associated anomalies. In a
citation reviewing 185 such cases, 70 (38%) were completely absent, 60
(32%) were rudimentary, and 55 (30%) were a fibrous structure.
Duplication
The reported incidence is 1 in 4000 persons. A true duplicated
gallbladder is found to have 2 distinct cavities each drained by a
separate cystic duct. The two cystic ducts may either unite or enter the
common bile duct separately.
Floating Gallbladder
This type of gallbladder is entirely surrounded by peritoneum
and is attached to the liver bed by a peritoneal reflection. It has 5%
incidence. This attachment if includes only the cystic duct, the
gallbladder remains unsupported. Torsion of such a gallbladder may
occur in seventh decade and presents as an emergency which requires
removal.
C) Vascular
Around 50% of people have variations in arterial anatomy.
Double cystic arteries are found in 15-20% of people, which course
through Calot’s triangle and can be inadvertently injured during
cholecystectomy. Triple cystic arteries are much rarer with an incidence
of less than 1%.
Figure
PHYSIOLOGY:
FUNCTIONS OF THE GALLBLADDER:
A) CONCENTRATION OF BILE:
The absorptive power of gallbladder mucosa is astonishingly
great as compared to any other organ as bile gets concentrated by
around five fold. Around 500
to a mere 30- 60ml. The main driving force for concentration of bile is
the ability to actively transport Sodium and Chloride, which is followed
by the passive reabsorption of water.
Figure 9. Anomalies of cystic artery
FUNCTIONS OF THE GALLBLADDER:
CONCENTRATION OF BILE:
The absorptive power of gallbladder mucosa is astonishingly
great as compared to any other organ as bile gets concentrated by
Around 500-1000 ml of hepatic bile gets concentrated
The main driving force for concentration of bile is
the ability to actively transport Sodium and Chloride, which is followed
by the passive reabsorption of water.
The absorptive power of gallbladder mucosa is astonishingly
great as compared to any other organ as bile gets concentrated by
1000 ml of hepatic bile gets concentrated
The main driving force for concentration of bile is
the ability to actively transport Sodium and Chloride, which is followed
Figure 10
Absorption of organic compounds like bilirubin, cholesterol,
phospholipids, and bile salts also occurs but that is much less when
compared with that of water. Therefore these organic compo
significantly concentrated by the normal absorptive function of the
gallbladder.
Unconjugated bile salts get more easily absorbed in contrast to
conjugated bile salts. It happens by bacterial deconjugation of bile salts
and in mucosal inflammation
which would end up in a nonselective increase in absorption of other
solutes, which in turn would impair the solubility of cholesterol and
result in stone formation.
10. Gallbladder mucosal absorption
Absorption of organic compounds like bilirubin, cholesterol,
phospholipids, and bile salts also occurs but that is much less when
compared with that of water. Therefore these organic compo
significantly concentrated by the normal absorptive function of the
Unconjugated bile salts get more easily absorbed in contrast to
conjugated bile salts. It happens by bacterial deconjugation of bile salts
and in mucosal inflammation. This damages the gallbladder's mucosa
which would end up in a nonselective increase in absorption of other
solutes, which in turn would impair the solubility of cholesterol and
result in stone formation.
Absorption of organic compounds like bilirubin, cholesterol,
phospholipids, and bile salts also occurs but that is much less when
compared with that of water. Therefore these organic compounds get
significantly concentrated by the normal absorptive function of the
Unconjugated bile salts get more easily absorbed in contrast to
conjugated bile salts. It happens by bacterial deconjugation of bile salts
. This damages the gallbladder's mucosa
which would end up in a nonselective increase in absorption of other
solutes, which in turn would impair the solubility of cholesterol and
C) SECRETION:
The gallbladder secretes two important substances namely mucin
glycoproteins and hydrogen ions. The former is thought of as an
important pronucleating agent, while the latter acidifies hepatic bile and
prevents precipitation of calcium salts. The secretion of mucin
glycoproteins is aided by prostaglandins . The mucin layer is considered
to protect against damage caused by unconjugated bile salts.
The transport of hydrogen ions across the gall bladder epithelium
occurs by means of sodium exchange. This leads to acidification of bile
resulting in a pH of 7.1- 7.3, which has an implication in calcium
solubility, by preventing precipitation of calcium salts. Comparatively,
the hepatic bile is slightly alkaline (pH 7.5-7.8) and its loss culminates
in metabolic acidosis.
(D) MOTILITY
During fasting, the sphincter of ampulla is tonically contracted
which produces a pressure of 10-15 mmHg in the common bile duct and
the gallbladder gets passively filled with bile (11). This does not happen
in a continuous fashion though, and is interrupted by short episodes of
emptying, which occurs in co-ordination with passage of an MMC
(Migratory motor complex) in the duodenum and the process is
mediated by Motilin [12]. During meals however, the sphincter of Oddi
relaxes and allows emptying of the gallbladder ( 50 -70 % of volume)
that lasts for 30 -40 minutes, aided by cholecystyokinin. Over the next
60 -90 minutes, the gallbladder refills gradually. Any interruption of this
sequence leads to bile stasis which is lithogenic [13].
COMPOSITION OF BILE:
Bile salts form the major component of bile. The other
constituents are bilirubin cholesterol, lecithin, and electrolytes. The
gallbladder by reabsorbing water and most of the electrolytes (except
calcium ions), concentrates bile and so bile from the liver varies entirely
when compared to that from the gallbladder.
PATHOLOGY OF GALL BLADDER
CHOLELITHIASIS [GALL STONES]
INCIDENCE: The prevalence of gallstones in India is about 10%,
about half of that in the western world (14). The disease is about 3 times
more common in women, though the prevalence depends upon various
risk factors.
RISK FACTORS (15)
NONMODIFIABLE
Female gender.
Increasing age.
Genetic factors: ethnicity (Pima tribes of south Arizona,
American Indians), family (16)
MODIFIABLE
Hypertriglyceridaemia.
Cholesterol lowering agents
multiparity
Ileal resection (17)
Gallbladder stasis (HyperalimentationTotal parenteral nutrition,
fasting)
Diet (high calories, low fibre, low calcium and vitamin C)
Alcohol abstinence
Smoking
Sedentary behaviour
PATHOGENESIS OF CHOLESTEROL STONES:
The stages involved are
Cholesterol supersaturation of bile.
Nucleation
Growth of stone.
i- CHOLESTEROL SATURATION:
THE CONCEPT OF MICELLES: The nonpolar cholesterol is
kept in solution by the formation of micelles, the bile salt–phospholipid-
cholesterol complex. In aqueous solutions, bile salts are oriented with
the hydrophilic portion outward. The phospholipids that are
incorporated into the micelle rstructure, allows cholesterol to be added
to the hydrophobic central part. When the micelles are saturated with
cholesterol, the excess comes out of solution and precipitates as
crystals [18, 19].
Figure
The key to maintaining cholesterol in solution is by the formation
of micelles, a bile salt
cholesterol-phospholipid vesicles.During excess cholesterol production,
the capacity of these vesicles as well as the micelles
crystal precipitation occurs. Due to the fact that cholesterol crystal
precipitation occurs preferentially by vesicular rather than micellar
mechanisms, the ultimate effect of concentrating bile is an increased
tendency to nucleate cho
By plotting the percentages of each component on triangular
coordinates, the micellar zone in which cholesterol is completely soluble
can be demonstrated. In the area above the curve, bile is supersaturated
Figure 11. Strucure of a Micelle
The key to maintaining cholesterol in solution is by the formation
of micelles, a bile salt–phospholipid-cholesterol complex, and
phospholipid vesicles.During excess cholesterol production,
the capacity of these vesicles as well as the micelles is exceededand
crystal precipitation occurs. Due to the fact that cholesterol crystal
precipitation occurs preferentially by vesicular rather than micellar
mechanisms, the ultimate effect of concentrating bile is an increased
tendency to nucleate cholesterol [20].
By plotting the percentages of each component on triangular
coordinates, the micellar zone in which cholesterol is completely soluble
can be demonstrated. In the area above the curve, bile is supersaturated
The key to maintaining cholesterol in solution is by the formation
cholesterol complex, and
phospholipid vesicles.During excess cholesterol production,
is exceededand
crystal precipitation occurs. Due to the fact that cholesterol crystal
precipitation occurs preferentially by vesicular rather than micellar
mechanisms, the ultimate effect of concentrating bile is an increased
By plotting the percentages of each component on triangular
coordinates, the micellar zone in which cholesterol is completely soluble
can be demonstrated. In the area above the curve, bile is supersaturated
with cholesterol, and precipitation of
[18, 19].
Figure 12 Triangular phase diagram showing cut off point of cholesterol
The second step is accelerated nucleation or the rapid transition
from liquid to crystal,
factors or absence of nucleation inhibitors. It is
cholesterol monohydrate crystals form and aggregate to become
macroscopic.
Mucin glycoproteins act as pronucleating agents for c
crystallization. Many heat labile glycoproteins in the bile of gallstone
with cholesterol, and precipitation of cholesterol crystals occurs
Triangular phase diagram showing cut off point of cholesterol
crystal precipitation
The second step is accelerated nucleation or the rapid transition
crystal, which occurs when there are excess nucleation
factors or absence of nucleation inhibitors. It is the process by which
cholesterol monohydrate crystals form and aggregate to become
ucin glycoproteins act as pronucleating agents for cholesterol
Many heat labile glycoproteins in the bile of gallstone
l crystals occurs
Triangular phase diagram showing cut off point of cholesterol
The second step is accelerated nucleation or the rapid transition
which occurs when there are excess nucleation
the process by which
cholesterol monohydrate crystals form and aggregate to become
holesterol
Many heat labile glycoproteins in the bile of gallstone
patients have been identified as potential pronucleating factors.
Gallbladder mucus is the matrix on which cholesterol crystals aggregate.
The third step is the growth of the stone.
Besides gallbladder hypomotility, altered prostaglandin
metabolism also plays it role in the genesis of gallstone.
Figure 13. The process of cholesterol stone formationThe process of cholesterol stone formation
PATHOGENESIS OF PIGMENT STONES:
Pigment stones contain <20% cholesterol and are dark due to the
presence of calcium bilirubinate.
Black pigment stones are formed by supersaturation of calcium
bilirubinate, carbonate, and phosphate, mostly secondary to hemolytic
disorders like hereditary spherocytosis and sickle cell disease, and in
those with cirrhosis. They are usually small, brittle and black.
Brown pigment stones are secondary to bacterial infection, Beta-
glucuronidase in E.coli enzymatically cleaves bilirubin glucuronide to
produce the insoluble unconjugated bilirubin, which precipitates with
calcium, and along with dead bacterial cell bodies, forms soft brown
stones.
GALLSTONES IN THE NON-OBESE:
Non-obese patients have a diminished expression of apical
sodium-dependent bile acid transporter (ASBT) in terminal ileum.
Also in Crohn's ileitis, there’s a significant downregulation of this
transporter (21).
NATURAL HISTORY:
Most gallstones are asymptomatic. Only 1% to 2% of patients
ultimately need intervention, either surgical or endoscopic. The
spectrum of symptomatic cholelithiasis ranges widely from biliary colic
to acute and chronic complications. On an average, asymptomatic
individuals develop symptoms at the rate of 3% per year. Once
symptomatic, episodes of biliary colic keep recurring. Out of those that
recur, the incidence of complications is 3-5% per year. Roughly two
thirds of asymptomatic patients with gallstones remain so over 20 years.
Generally mildly symptomatic patients go for cholecystectomy due to
severe symptoms at the rate of 6% to 8% per year in the early years and
gradually decreasing with longer follow-up (22,23).
CLINICAL MANIFESTATIONS
GALL BLADDER DYSPEPSIA
The constellation of symptoms like belching, burping, heartburn
and epigastric discomfort experienced after a fatty meal constitutes
‘dyspepsia’, which classically occurs in gallstone disease.
ACUTE CHOLECYSTITIS
When the gallstone obstructs the cystic duct by a gallstone, a
series of events initiated by the mucosal lysolecithin follow, that is
distention of the gallbladder, inflammation and edema of the wall,
which when superimposed with bacterial infection causes haemorrhage
and necrosis of the gallbladder wall with pericholecystic fluid
collection. In the severe form which occurs in 5-10 % of cases, ischemia
and necrosis of the wall occurs (Gangrenous cholecystitis) and in cases
of infection with gas forming organisms, an emphysematous gallbladder
results. Sometimes with unresolving sepsis, the gallbladder may
perforate secondary to an empyema, which is sometimes contained by
the omentum or may end up in intraperitoneal abscess or a
cholecystoenteric fistula occur.
Rarely a cystic duct stone can obstruct the common bile duct due
to the surrounding severe inflammation (Mirizzi's syndrome).
The timing of cholecystectomy in case of acute cholecystitis is a
matter of debate. A prospective randomized controlled trial by Lai Ec et
al in 1998 compared the results of early (within 72 hours of admission)
and delayed cholecystectomy and showed no significant differences in
morbidity or mortality, although the delayed group ended up in a
significantly prolonged hospital stay (11 vs. 6 days) and recovery period
(19 vs. 12 days) [24, 25, 27].
BILIARY PANCREATITIS
Gallstones which are less than 5 mm in size and multiple stones
have the risk of causing acute pancreatitis [26]. Stone impaction at the
ampulla leads to blockage of pancreatic secretions and results in
pancreatitis. A severe form of biliary pancreatitis needs an ERCP
(Endoscopic retrograde cholangiopancreatography) and sphincterotomy,
followed by cholecystectomy once the severity subsides. These patients
must have an intraoperative cholangiogram
INVESTIGATIONS OF GALLSTONE DISEASE
BLOOD INVESTIGATIONS
In evaluating a case of suspected cholelithiasis, a complete
hemogram and liver function tests are routinely done. An increase in the
total white blood cell (WBC) count is suggestive of cholecystitis and if
an elevated total bilirubin, alkaline phosphatase, and aminotransferase
are found, once should think in terms of cholangitis. Increased total
bilirubin and serum alkaline phosphatase go in favour of cholestasis.
SONOLOGY IN GALLBLADDER DISEASE: It is a proven fact that
ultrasonogram is the initial investigation of choice in evaluating
gallstone disease. Ultrasonogram identifies stones as small as 2mm with
a sensitivity of 95%.Althoughit is operator- dependent, the ease of
availability and cost effectiveness makes it the ideal investigation.
Stones are detected by their post acoustic shadow. Calcified polyps are
differentiated from stones by the fact that the former is static while the
latter has postural variation of location. Besides establishing the
diagnosis, it is also a useful tool to predict the amount of difficulty
involved in laparoscopic cholecystectomy [28, 29]
The factors that have been found to significantly influence the
outcome by Jansen et al in 1997were large stones (2cm ), a thick walled
gallbladder (>0.4cm) , a dilated common bile duct (> 0.6cm)on
ultrasound. The number of stones in the gallbladder did not seem
significant [58]. With a gall bladder wall thickness of > 0.4cm, surgery
would be technically demanding, as it would be difficult to grasp. A
preoperative ultrasound also helps to identify wall calcifications which
might pose difficulty in grasping and retraction during laparoscopic
cholecystectomy [30,31].
ORAL CHOLECYSTOGRAPHY
Ever since its introduction in 1924 by Graham and Cole, it
continued to be the primary investigatory modality until replaced by
ultrasonography. Stones are identified by the presence of filling defects
in the visualised gallbladder. This is not useful in patients with
obstructive jaundice, liver cell failure and intestinal malabsorption.
BILIARY SCINTIGRAPHY (HIDA SCAN):
It is a noninvasive investigation which delineates both anatomy
and function of the biliary tree.99mTechnetium-labeled hepatic
iminodiacetic acid (HIDA) is given intravenously. The
reticuloendothelial cells clear the liver off the contrast and excrete the
same through bile which is detected by gamma camera. The uptake
detected at 10 minutes images the liver and the one detected over 60
minutes images the rest of the biliary tree [32]. Its prime usage is in
diagnosing acalculous cholecystitis (biliary dyskinesia) wherein the
gallbladder is not visualised in contrast to the readily apparent common
bile duct and duodenum. False-positive results are obtained in
conditions of gallbladder stasis (critically ill patients, patients on total
parenteral nutrition.
COMPUTED TOMOGRAPHY (CT):
CT scan of the abdomen is considered inferior to ultrasonography
for the diagnosis of gallstones and it’s mainly used to define and
delineate extrahepatic biliary tree and other adjacent structures. .
MAGNETIC RESONANCE IMAGING (MRI)
MRI and MRCP (Magnetic resonance cholangiopancreatography)
are the ultimate choices when it comes evaluating biliary tract disease.
This is required when the presence of common bile duct (CBD) stones
are suspected, as in cases with a dilated CBD and dilatation of the
intrahepatic biliary radicals [33].MRCP identifies bile ducts as high-
signal-intensity structures in heavily T2-weighted sequences and
recently pulse sequences have been defined so as to generate high
resolution images.
COMPLICATIONS OF GALLSTONES [34, 35]
Acute and chronic cholecystitis
Emphysematous cholecystitis
Empyema gallbladder
Gallbladder perforation
Biliary pancreatitis
Cholangitis
Mirizzi’s syndrome
Gallstone ileus
Cholecysto-enteric fistula
Gastric outlet obstruction (Bouveret’s syndrome)
Carcinoma gallbladder with stones > 3cm size and calcified
gallbladder
MANAGEMENT OF GALLSTONES- NONOPERATIVE
Nonoperative Therapies for Symptomatic Gallstones
AGENT ADVANTAGES DISADVANTAGES
Oral bile acid dissolution: ursodeoxycholic acid (Actigall),
at 8 to 10 mg per kg per day
Stone clearance: 30 to 90 percent
with zero percent
mortality
50 percent recurrence of stones; dissolves
noncalcified cholesterol stones;
optimal for stones < 5 mm; symptom relief
does not start for 3 to 6 weeks; may take 6
to 24 months for
results
AGENT ADVANTAGES DISADVANTAGES
Contact solvents: methyl tert-
butyl ether/ n-propyl acetate
Stone clearance:
50 to 90 percent
70 percent recurrence
of stones;
experimental, with insufficient data;
duodenitis;
hemolysis;
nephrotoxicity; mild sedation
Extracorporeal shock-wave
lithotripsy: electrohydraulic/electromagnetic
Stone clearance:
70 to 90 percentwith<
0.1 percent
mortality
70 percent recurrence;
not approved by FDA; performed only
at centers with
expertise; selection
criteria require no more than one
radiolucent stone (<
20 mm in diameter),
patent cystic duct, functioning
gallbladder in a patient with
symptomatic gallstones without
complications
FDA = U.S. Food and Drug Administration.
Ref:AIJAZ AHMED, M.D., RAMSEY C. CHEUNG, M.D., and
EMMET B. KEEFFE, M.D.,Management of Gallstones and Their
ComplicationsAmFam Physician. 2000 Mar 15;61(6):1673-1680.
OPERATIVE MANAGEMENT OF GALLSTONES:
CHOLECYSTECTOMY – ANATOMIC CONSIDERATIONS:
The success of any surgery lies upon the adequacy and accuracy
of anatomical knowledge and this holds true here as well. Iatrogenic
injuries most often occur due to unidentified anomalies.
One has to identify the Calot’s and the Moosman’s triangles,
ensure the identity of the structures passing through, before intervening.
An aberrant right hepatic artery arising from the superior mesenteric
artery can courses through the medial aspect of the Calot’s triangle, with
cystic duct lying anterior to it. Accessory hepatic ducts may also
traverse the Calot’s triangle. Hence adequate visualisation of the
anatomy is of paramount importance in any form of cholecystectomy.
The origin of the cystic artery, the junction of cystic duct with common
hepatic duct may be anomalous many a time and should be looked for.
An intra-operative cholangiogram can be helpful in difficult situations.
Indications and Relative Indications for an Open Cholecystectomy
Severe cholecystitis (relative)
Inability to delineate anatomy during laparoscopic cholecystectomy
Emphysematous gallbladder (relative)
Suspicion for gallbladder cancer
Perforation of gallbladder/abscess
Fistulization of gallbladder gallstone ileus (relative)
Cholangitis (relative)
Multiple past abdominal procedures (relative)
Pregnancy (relative)
Cirrhosis/portal hypertension (relative)
Blood dyscrasias (relative)
Contraindication for laparoscopy
Relative Indications for Prophylactic Cholecystectomy
Cardiac transplant recipients
Lung transplant recipients
Chronic total parenteral nutrition requirement
Recipients of biliopancreatic diversion (bariatric patients)
Family history of gallbladder cancer and asymptomatic stones
Children with hemoglobinopathy (sickle cell, thalassemia,
spherocytosis)
Cholelithiasis encountered during elective abdominal procedures
INDICATIONS FOR LAPAROSCOPIC CHOLECYSTECTOMY:
A) Symptomatic gallstones
Biliary colic
Acutecholecystitis
Chronic cholecystitis
Gallstone pancreatitis
B) Asymptomatic Gallstones
Total parenteral nutrition
Sickle cell anemia
Chronic immunosuppression
Lack of immediate access to tertiary care
(military personnel, relief workers)
Biliary dyskinesia
Polyp > 10mm
Porcelain gall bladder
CONTRAINDICATIONS TOLAPAROSCOPIC
CHOLECYSTECTOMY:
A) ABSOLUTE:
Contraindication to general anaesthesia
Bleeding disorder
Gallbladder malignancy in doubt
B) RELATIVE
Morbid obesity
Peritonitis
Cholangitis
Chronic obstructive lung disease
Liver cirrhosis
Pregnancy
History of upper abdominal surgery
LAPAROSCOPIC CHOLECYSTECTOMY
OPERATING ROOM SET-UP
Two techniques have been described, the American and the
French technique. The Americans advocate the surgeon to approach
from the patient’s left side and the first assistant to be on the patient's
right side.
The French technique is the one in which the surgeon stands in
between the patient's abducted legs.
PNEUMOPERITONEUM
This again could be achieved by either the closed or the open
Hasson’s technique.CO2, the non-combustible gas is quite safe, though
there are reported incidences of hypercarbia secondary to
cardiopulmonary disease.
PORT PLACEMENT AND EXPOSURE
In the conventional technique, two 5mm and two 10mm ports are
used. The 10 mm ports are made, one each in the umbilical and
epigastric regions, and the 5mm ports are made in the right subcostal
region, one each in anterior axillary line and midclavicular line.
PROCEDURE
With a cephalad traction at the fundus and a lateral traction at the
infundibulum, Calot’s triangle comes into view and one has to stay
parallel to cystic duct. Once the cystic duct and artery are identified and
skeletonised, it would be ideal to visualise the Rouviere’s sulcus and
dissection should not proceed any further.
in the Calot’s triangle, the
identified to prevent bile duct
Figure
Figure 15
skeletonised, it would be ideal to visualise the Rouviere’s sulcus and
ion should not proceed any further. After clearing the structures
in the Calot’s triangle, the Strasberg’s Crtical View of Safety is
identified to prevent bile duct injury.
Figure 14 A View of Calot's Triangle
15 Strasberg's Critical View Of Safety
skeletonised, it would be ideal to visualise the Rouviere’s sulcus and
After clearing the structures
Strasberg’s Crtical View of Safety is
Clips are applied over the cystic artery and duct. Essentially the
artery should be divided first for two reasons : 1- division of the artery
results in lengthening of the cystic duct by a few mm which can be
safely divided, 2- if bleeding occurs, one might mistake common bile
duct for cystic duct while clamping. Gallbladder is dissected off the
liver bed and hemostasis ensured. Following port closure, analgesic
infiltration is given at the post sites for postoperative pain relief.
INTRAOPERATIVE GALLBLADDER PERFORATION
Perforation of the gallbladder occurs due to excessive traction or
by electrocautery and can lead to spillage of bile and stones. The spilled
stones if contain cholesterol predominantly carry little risk of infection
which is not true with pigment stones [36].
Studies have shown no significant increase in morbidity with
spillage of stones, except for an increased operating time.
LAPAROSCOPIC APPROACH- THE SAFETY CHECKLIST:
1. Optimal visualisation- 30 degree scope
2. Clear view of Calot’s triangle and cystic duct – Gallbladder
junction
3. Lateral retraction of infundibulum and cranial retraction of
fundus
4. To establish Strasberg’s Critical view
5. To minimise electrocautery dissection close to Common
bile duct
6. To visualise cystic duct before clip application.
COMPLICATIONS OF LAPAROSCOPIC
CHOLECYSTECTOMY:
Intra operative
i)Related to pneumoperitoneum
CO2 embolism
Vasovagal reflex
Cardiac arrhythmia
Hypercarbic acidosis
ii)Trocar related
Bowel injury
Vascular injury
iii) Dissection related
Injury to cystic artery
Injury to bile duct
Retained stones
Bile leakage
Post operative
Wound infection
Bile leak
Basal atelectasis
Incisional hernia
COMPARISON OF VARIOUS SERIES OF LAPAROSCOPIC
CHOLECYSTECTOMY:
SERIES YEAR CONVERSION
RATE %
BILE DUCT
INJURIES %
Cushieri, et al 1991 2.6 0.3
Scott, et al 1992 4.3 0.4
Litwin, et al 1992 4.3 0.1
Orlando, et al, 1993 6.9 0.3
Fullarton, et al 1994 17 0.7
Brune, et al 1994 1.2 0.2
PROSPECTIVE TRIALS COMPARING LAP VS OPEN
CHOLECYSTECTOMY
Series Year Complications
(%)
Duration of
hospitalisation
(days)
Time taken to
return to duty
(days)
Barkun,et al, 1992
OC 8.0 4* 20*
LC 2.7 3 12
Trondsen, et
al
1993
OC 20 4* 34*
LC 17 3 11
Berggren, et
al
1994
OC — 3* 24*
LC — 2 12
Kiviliuto, et
al
1998
OC 23* 6* 30
LC 3 4 14
LAPAROSCOPIC VS OPEN APPROACH- COMPARED AND
CONTRASTED:
Laparoscopic cholecystectomy (LC) has its own merits and
demerits. Though the rate of complications were much higher than open
surgery during the early periods after its introduction, say in the
1990’s, as reported by Fletcher et al in 1999 of an increase in the
intraoperative complication from 0.67% to 1.33% [34]. But recent
evidence states that LC entails lower morbidity and mortality rates than
open operation. The morbidity rate for an open cholecystectomy ranges
from 5% to 20% as compared to 1.5-8.6% with laparoscopic
cholecystectomy. Jatzko et al in a mutivaraiate analysis came out with a
report of 7.7% morbidity rate from open surgery as compared to 1.9%
for LC and5% mortality rate vs 1% for LC [37, 38, 39]. But the same is
not applicable for bile duct injuries as is evident from various studies.
Roslyn et al had shown an incidence of 0.2% bile duct injuries [35] from
42,000 open cases as against 0.4-1.3% from laparoscopic
cholecystectomies
ADVANTAGES OF LAPAROSCOPIC CHOLECYSTECTOMY:
Better cosmesis
Less pain
Decreased length of hospital stay
Earlier return to work
Less overall cost
DISADVANTAGES
Lack of depth perception
Decreased tactile discrimination
Bleeding difficult to control
View control lies in hands of camera operator
Complications of pneumoperitoneum
Despite the positive trend in the number of surgeries performed
and the favourable outcomes, open surgery or an early conversion to
open is the choice when it comes to complicated cases. In patients
presenting with minimal symptoms, the chances of a difficult outcome
needs to be predicted as the complications, if occur are difficult to
manage. This indeed would enable a beginner to approach the cases
with more confidence and also lessen the avoidable morbidity to the
patient.
WHAT’S NEW?
OUT PATIENT LAPAROSCOPIC CHOLECYSTECTOMY:
The concept of Out Patient laparoscopic cholecystectomy (LC)
has been in practise for about a decade. Bueno et al in 2006, shared his
experience from 504 cases of outpatient LC and reported an ambulatory
percentage of 88.8% with a mean hospital stay of 6.1 hours.
The complication rate was 11.6% and 10.1% of them required overnight
stay [40].
Inspite of promising results, the acceptance rate remains low and
the potential barriers evaluated are found to be medical and institutional,
with medical barriers being patient comorbidities. Forrest et al in 2001
formulated a consensus protocol incorporating comprehensive health
education and a multidisciplinary approach to overcome such barriers
[41] which promoted a significant increase in the acceptance rate from
21% to 72%
Voyles et al formulated selection criteria to ensure safety of the
procedure which included age less than 65, absence of upper abdominal
operations, and elective operations in healthy patients at low risk for
common bile duct stones. Therefore with a careful patient selection and
adequate surgical expertise, LC can be a safe outpatient surgery [42].
MINILAP
Mini port laparoscopic surgery was another step towards
improved cosmesis. It involves the use of 10-mm umbilical, 5-mm
epigastric, 2-mm subcostal, and 2-mm lateral ports. The results of
Novitsky et al showed decreased early postoperative incisional pain,
late incisional discomfort and superior cosmetic results, though not
statistically significant [43,44].
SILS
Yet another less invasive surgical procedure in the era of
minimal access surgery is SILS. Using a single 12mm incision at the
umbilicus and a 5mm trocar introduced through the same, peritoneal
cavity is viewed with a 5mm, 30degree optic. The 2nd and 3rd trocars are
introduced to the left and right of the 5 mm trocar. With two sutures to
suspend GB, Calot’s triangle evaluated and dissection performed using
endoshear roticulator on the left and an endograsp roticulator on the
right. Tacchino et al in 2009 reported a decrease in operating time from
an initial 3 hours to 50 min after the first five cases in his series of 12
cases [45].A recent study states that the improved cosmesis associated
with SILS happens so at the cost of increased port site hernia rates of
8.4% as compared to 4% with conventional LC ( Marks et al , 2013).
Yet cosmesis scores continue to favour SILS [45].
NOTES
Portugal et al used transgastric and transvesical approach to
cholecystectomy. The first series of transvaginal NOTES
cholecystectomy was performed by a Research Group led by Ricardo
Zorron in March 2007. Since it involves the use of flexible endoscopes
that result in partial loss of spatial orientation and depth perception,
there has been focus on getting computer assisted images [46, 47].
PREOPERATIVE PREDICTION –THE NEED OF THE HOUR
Laparoscopic Cholecystectomy is the treatment of choice for
symptomatic cholelithiasis. It is also associated with the worst of
complications, which, when encountered cripples the patient as well as
the surgeon. It would be extremely useful to have a method by which
significant risk factors could be analysed preoperatively and to identify
patients at potential risk of developing complications.
By identifying parameters that would predict conversion, better
perioperative planning, patient counselling, optimum operating room
efficiency and risk stratification could be achieved and patient safety
ensured. It helps in guiding a surgeon intraoperatively in decision
making and the need for early conversion. Data suggest a 4 fold increase
in the risk of complications when the duration of surgery exceeds 2
hours [37].
Risk stratification determines the duration of trial dissection, with
an inclination to convert if no progress is noted during dissection of the
Calot’s triangle over half an hour for those at high risk. For low risk
patients, this could be extended to 1 hour and if there seems a possibility
of dissection, one can proceed with the surgery.
PARAMETERS THAT PREDICT A DIFFICULT LC
Various studies have been conducted worldwide to identify the
set of factors that have an implication on the conversion rates. They
include clinical, biochemical and sonological parameters and their
influence has been validated in both elective and emergency settings
[48-51].
Many clinical parametershave been studied including, age,
gender, obesity, addictive habits, comorbidities like chronic obstructive
pulmonary disease, diabetes mellitus, liver cirrhosis, history of previous
abdominal surgery, signs of acute cholecystitis like right hypochondrial
tenderness or a palpable gall bladder. Also the preoperative ASA
(American Society of Anaesthesiologists) classification, the timing
of surgery, whether in an elective or emergency setting has been
analysed [48].
Many studies support the influence of biochemical parameters
like hyperbilirubinemia, hypoalbuminemia and leucocytosis on the
outcome.
The sonological features that should warn the surgeon
preoperatively include presence of fluid around gallbladder, thickened
wall, stone impaction at the neck and a dilated common bile
duct [57, 58].
There have been attempts to developing a scoring system which
would help in risk stratification of patients. Yet there’s no system which
has been found significant and widely accepted.
Our study being conducted at an elective setting did not include
laboratory criteria.
AIMS AND OBJECTIVES OF THE STUDY:
To determine the possibility of predicting preoperatively a
difficult laparoscopic cholecystectomy
To determine the factors which significantly predict the
outcome
To identify patients at risk in an elective setting and thereby
enable patient counselling.
MATERIALS AND METHODS:
PLACE OF STUDY: Department Of General Surgery, Stanley
Medical College, Chennai.
PERIOD OF STUDY: JANUARY – NOVEMBER 2013.
STUDY DESIGN: PROSPECTIVE ANALYTICAL STUDY
The study was approved by the Ethical Committee, Stanley
Medical College.
INCLUSION CRITERIA:
All cases of symptomatic uncomplicated cholelithiasis
EXCLUSION CRITERIA:
Patient not willing for laparoscopic cholecystectomy
Patient who are not fit for laparoscopic surgery. Eg. Severe
COPD
Patient with acute cholecystitis, gall stone pancreatitis, empyema
gall bladder
Patients with coexisting Common Bile Duct stones and dilated
common bile duct, requiring procedures additional to
cholecystectomy.
Cases requiring conversion due to technical failure.
METHODOLOGY:
Patients with symptoms suggestive of cholelithiasis were
subjected to complete clinical, biochemical and radiological
investigations. 40 patients who met the inclusion criteria and planned
for elective surgery and operated upon by a single experienced
laparoscopic surgeon were studied after getting their consent.
After complete clinical and radiological evaluation, 9
characteristics were analysed and patients were assigned scores based
on their history, clinical examination and sonological findings (Table 1)
one-day prior to surgery. Score upto 5 was designated as easy, 6–10 as
difficult and 11–15 as very difficult. The outcome was defined based on
prefixed criteria as per Table 2.
Surgery was done using CO2 pneumoperitoneum with 12mm Hg
pressure and using standard two 5 mm and two 10 mm ports. The timing
was noted from incision for the first port until the closure of the last
port. The intraoperative events were recorded. All cases received
standard postoperative care and follow up.
Statistical analysis was done using Chi-square test and Fischer’s
exact t test for analysing the significance of the variables and Microsoft
excel for tabulation.
TABLE 1-Scoring Methodology
Age Scoring Pattern
Less than 50 0
Above 50 1
Gender
Female 0
Male 1
Previous
Hospitalization
Yes 4
No 0
Body Mass Index
Up to 25 0
25 to 27.5 1
Above 27.5 2
Abdominal Scar
No 0
Infraumbilical scar 1
Supraumbilical Scar 2
Palpable GB
Yes 1
No 0
Wall Thickness
Yes 1
No 0
Impacted Stone
Yes 1
No 0
TOTAL SCORE 15
Outcome
EASY Less than 5
DIFFICULT 6 to 10
VERY DIFFICULT Above 10
TABLE 2
OUTCOME CRITERIA
EASY TIME<60 MINUTES
NO BILE/STONE SPILLAGE
NO DUCT/ARTERIAL
INJURY
DIFFICULT TIME 60-120 MINUTES
BILE/STONE SPILLAGE
VERY DIFFFICULT TIME>120 MINUTES
DUCT/ ARTERIAL INJURY
CONVERSION
OBSERVATION AND RESULTS:
From a total no.of
following analysis was made.
TABLE 3: PATTERN OF OUTCOME
Outcome
No. of Easy Cases
No. of Difficult Cases
No. of Very Difficult Cases
FIGURE1: PATTERN OF
Out of the 40 cases, 9 turned out to be difficult and 2 were very difficult.
9
OBSERVATION AND RESULTS:
From a total no.of 40 patients who met the inclusion criteria, the
following analysis was made.
TABLE 3: PATTERN OF OUTCOME
Numbers Percentage
26 72.5
No. of Difficult Cases 9 22.5
No. of Very Difficult Cases 2 5.0
FIGURE1: PATTERN OF OUTCOME
Out of the 40 cases, 9 turned out to be difficult and 2 were very difficult.
26
2
NO. OF CASES
EASY
DIFFICULT
VERY DIFFICULT
40 patients who met the inclusion criteria, the
Percentage
72.5
22.5
Out of the 40 cases, 9 turned out to be difficult and 2 were very difficult.
VERY DIFFICULT
TABLE4
Scoring Pattern
No. of Cases with Score < 5
No. of Cases with Score 5
No. of Cases with Score >10
With the aforementioned scoring applied to the cases, 30% of
them had a score of 5-10 and none of them met with a score greater than
10 including the very difficult cases.
FIGURE2: SCORE DISTRIBUTION
81.8% of difficult cases had a score of 5
scored greater than 10.
0%
20%
40%
60%
80%
100%
SCORE <5
SCORE DISTRIBUTION
Scoring Pattern Numbers Percentage
No. of Cases with Score < 5 28 70.0
No. of Cases with Score 5-10 12 30.0
No. of Cases with Score >10 0 0.0
aforementioned scoring applied to the cases, 30% of
10 and none of them met with a score greater than
10 including the very difficult cases.
FIGURE2: SCORE DISTRIBUTION
81.8% of difficult cases had a score of 5-10 and none of them
SCORE <5SCORE 5-10
SCORE >10
SCORE DISTRIBUTION
DIFFICULT
EASY
Percentage
aforementioned scoring applied to the cases, 30% of
10 and none of them met with a score greater than
10 and none of them had
DIFFICULT
FIGURE 3: AGE AND OUTCOME
9 patients with age > 50 and 2 patients with age <50 had a difficult
outcome and it was a significant factor with p value 0.000.
FIGURE 4. GENDER AND OUTCOME
6 out of 13 males and 5 out of 2
and this was not found to be significant ( p 0.055)
0
5
10
15
20
25
30
AGE < 50
0
5
10
15
20
25
FEMALE
FIGURE 3: AGE AND OUTCOME
9 patients with age > 50 and 2 patients with age <50 had a difficult
outcome and it was a significant factor with p value 0.000.
FIGURE 4. GENDER AND OUTCOME
6 out of 13 males and 5 out of 27 females had a difficult outcome
and this was not found to be significant ( p 0.055)
AGE > 50
DIFFICULT
EASY
MALE
DIFFICULT
9 patients with age > 50 and 2 patients with age <50 had a difficult
7 females had a difficult outcome
DIFFICULT
EASY
DIFFICU
FIGURE 5. BMI AND OUTCOME
8 out of 11 obese patients had a difficult outcome and obesity was
found to be a strongly significant factor (p 0.000).
FIGURE 6. H/O HOSPITA
9 out of 11 patients with history of hospitalisation had difficulty
and this factor was found to be strongly significant as well (p 0.000)
0
5
10
15
20
25
30
BMI < 25
0
5
10
15
20
25
30
35
YES
FIGURE 5. BMI AND OUTCOME
8 out of 11 obese patients had a difficult outcome and obesity was
found to be a strongly significant factor (p 0.000).
FIGURE 6. H/O HOSPITALISATION AND OUTCOME
9 out of 11 patients with history of hospitalisation had difficulty
and this factor was found to be strongly significant as well (p 0.000)
25-27.5 >27.5
DIFFICULT
EASY
NIL
DIFFICULT
EASY
8 out of 11 obese patients had a difficult outcome and obesity was
9 out of 11 patients with history of hospitalisation had difficulty
and this factor was found to be strongly significant as well (p 0.000)
DIFFICULT
EASY
DIFFICULT
FIGURE7.ABDOMINAL SCAR AND OUTCOME
9 out of 11 difficult cases did not have an abdominal
with supra umbilical scar one case had an easy outcome and this factor
was not found to be significant (p 0.058).
FIGURE 8.PALPABLE GALLBLADDER AND OUTCOME
0
5
10
15
20
25
30
NO SCAR INFRAUMBILICAL
0
5
10
15
20
25
30
35
40
YES
FIGURE7.ABDOMINAL SCAR AND OUTCOME
9 out of 11 difficult cases did not have an abdominal scar. Even
with supra umbilical scar one case had an easy outcome and this factor
was not found to be significant (p 0.058).
FIGURE 8.PALPABLE GALLBLADDER AND OUTCOME
INFRAUMBILICAL SCAR
SUPRAUMBILICAL SCAR
DIFFICULT
EASY
NIL
DIFFICULT
EASY
scar. Even
with supra umbilical scar one case had an easy outcome and this factor
FIGURE 8.PALPABLE GALLBLADDER AND OUTCOME
DIFFICULT
EASY
DIFFICULT
EASY
All 4 patients who presented with a palpable gallbladder had a
difficult outcome and th
FIGURE 9. THICKENED GALLBLADDER AND OUTCOME
4 out of 7 patients with a thickened gallbladder had a difficult
outcome and this factor too was found significant (p. 0.050)
FIGURE10. PERICHOLECYSTIC FLUID COLLECTIOUTCOME
0
5
10
15
20
25
30
35
YES
0
10
20
30
40
YES
All 4 patients who presented with a palpable gallbladder had a
difficult outcome and this factor was found significant (p 0.001).
FIGURE 9. THICKENED GALLBLADDER AND OUTCOME
4 out of 7 patients with a thickened gallbladder had a difficult
outcome and this factor too was found significant (p. 0.050)
FIGURE10. PERICHOLECYSTIC FLUID COLLECTION AND
NIL
DIFFICULT
EASY
NO
DIFFICULT
EASY
All 4 patients who presented with a palpable gallbladder had a
is factor was found significant (p 0.001).
FIGURE 9. THICKENED GALLBLADDER AND OUTCOME
4 out of 7 patients with a thickened gallbladder had a difficult
ON AND
DIFFICULT
EASY
DIFFICULT
Only two patients presented with pericholecystic fluid collection,
10 difficult cases out of 11 did not have pericholecystic fluid and this
factor was not found significant (p 0.464)
FIGURE11. IMPACTED STONE AND OUTCOME
Only one patient
difficult case. 10 out of 11 cases did not have impacted stones and this
factor was not found significant (p 0.100)
05
10152025303540
YES
Only two patients presented with pericholecystic fluid collection,
10 difficult cases out of 11 did not have pericholecystic fluid and this
factor was not found significant (p 0.464)
FIGURE11. IMPACTED STONE AND OUTCOME
Only one patient presented with impacted stone and his was a
difficult case. 10 out of 11 cases did not have impacted stones and this
factor was not found significant (p 0.100)
NO
DIFFICULT
EASY
Only two patients presented with pericholecystic fluid collection,
10 difficult cases out of 11 did not have pericholecystic fluid and this
presented with impacted stone and his was a
difficult case. 10 out of 11 cases did not have impacted stones and this
DIFFICULT
Figure 16 Difficult case showing bile and stone spillage
TABLE 5. OUTCOME ANALYSIS
Risk factors Level
Age <=50
>50
Sex Female
Male
Hospitalization Nil
Yes
BMI <=25
Difficult case showing bile and stone spillage
OUTCOME ANALYSIS
Level Peroperative Outcome
Difficutl No. (%)
Easy No (%)
<=50 2 (18.2%) 27 (93.1%)
9 (81.8%) 2 (6.9%)
Female 5 22
Male 6 7
2 28 (96.6%)
9 1 (3.4%)
<=25 3 (27.3%) 26
P Value
0.000**
0.055
0.000**
0.000**
(89.7%)
25.1- <=27.5 2 (18.2%) 3 (10.3%)
>27.5 6 (54.5%) 0 (0.0%)
Abdominal Scar
No 9 14 0.058
Infraumbilical scar
2 14
Supraumbilical Scar
0 1
Palpable GB Nil 7 (63.6%) 29 (100.0%)
0.001**
Yes 4 (36.4%) 0 (0.0%)
Wall Thickness
Normal 7 (63.6%) 26 (89.7%)
0.050*
Thickened 4 (36.4%) 3 (10.3%)
Peri GB collection
Nil 10 (90.9%) 28 (96.6%)
0.464
Yes 1(9.1%) 1(3.4%)
Impacted Stone
Nil 10 (90.9%) 29 (100.0%)
0.100
Yes 1(9.1%) 0 (0.0%)
ROC Curve analysis
Area Under the Curve = 0.967
The ROC curve analysis result showed that the best cutoff score
value to classify “Difficult” is ≥ 3. That is if the score is greater than or
equal to 3 we can say that it will a “Difficult”.
Sensitivity and Specificity analysis.
Out come Total
Difficult Easy
Score
classification
Difficult
(≥ 3)
11 3 14
Easy
(< 3)
0 26 26
Total 11 29 40
Parameter Estimate Lower - Upper 95% CIs
Sensitivity 100.00% (74.12, 100.00)
Specificity 89.66% (73.61, 96.42)
Positive Predictive Value 78.57% (52.41, 92.43)
Negative Predictive Value 100.00% (87.13, 100.00)
Diagnostic Accuracy 92.50% (80.14, 97.42)
DISCUSSION
Laparoscopic cholecystectomy is the fantasy of this era of
minimally invasive surgery. What would look simple might not be
simple all the time and in that case the consequences could be
devastating. Hence there needs to be a way in which a difficulty could
be anticipated preoperatively.
Of the multiple preoperative variables analysed, age > 50, history
of previous hospitalisation for an acute attack of cholecystitis, obesity,
palpable gallbladder and wall thickness > 4mm were found to be
significant predictors of a difficult outcome.
AGE.
81.8% of cases were associated with an age greater than 50 and
history of hospitalisation and were found to be strongly significant with
a p value of 0.000. As in our study, many series have reported an
association of advanced age and a difficult outcome [52, 53]. Fried et al
reported a conversion rate of 5.4% with increasing age and male gender
against a conversion rate of 1.9% for women younger than 50 years [52,
53, 56 and 60]. The strong association between age and a difficult
outcome could probably be due to the presence of comorbidities. Age
probably cannot be taken as an independent risk factor and its
association with multiple other factors in correlating with a difficult
outcome would be more meaningful.
GENDER
Male gender was a significant predicting factor in studies
conducted at many institutions worldwide, the same was true more so in
emergency settings [51, 53, 56]. In an elective setting, Jethwani et al
reported a conversion rate of 6.3% for men and 4.5% for women. On the
contrary, Jeremy et al reported a conversion rate of 12.6% ( double) for
men presenting with acute cholecystitis in his series involving 1377
patients in 2007.Our study, having been conducted at an elective setting,
we could not study the influence of gender on the outcome and in ours,
it turned out to be insignificant.
OBESITY
Obesity as a risk factor was observed in 72.7% of cases with a p
value of 0.000. Out of the 11 difficult cases, two cases had a score <5
and yet turned out to be difficult and in them the significant factor was
obesity. Rosen et al in his series of 1347 cases observed a body mass
index(BMI) >30kg/m2 as significant, while yet another recent study
conducted by Jaskiran et al states a BMI > 27.5 as significant. In the
range of 25-27.5, the coexistence of other factors resulted in a difficult
outcome, whereas in cases with a BMI greater than 27.5, obesity solely
was the significant predictive factor.
The risk could be well explained by factors such as difficult
access due to thick abdominal wall, difficulties in creating
pneumoperitoneum, fat laden omentum and falciform ligament which
hinder the view of Calot’s triangle and a fatty liver which would be
difficult to retract. Although obesity has been considered a risk factor
for increased conversion [51, 52, 53,60], it’s still not a contraindication
to laparoscopic surgery [59] and decision making should be
individualised.
PREVIOUS HOSPITALISATION
When it came to previous history of hospitalisation for acute
cholecystitis, 81.8% of difficult cases had a positive history and 90% of
times, individuals with a positive history had a difficult outcome and
therefore it was meaningful to assign this variable a score of 4. This is
supported by data from different institutions in studies conducted
nationwide [53, 54] as well as internationally. Nuri et al and Murat et al
found previous attack of cholecystitis to be a significant predictor [55].
PREVIOUS ABDOMINAL SURGERY
Simopoulos et al and Nuri et al in two different studies found
previous abdominal surgery to be significantly adding on to the risk of
getting a difficult outcome. But in our case it was not found to be
significant as most of them were cases of puerperal sterilisation. The
risk in cases with previous surgery is usually attributed to the scar,
which makes port entry difficult, though not encountered in our study
[55,56].
PALPABLE GALLBLADDER
Clinically palpable gallbladder has so far been included in only
one study conducted by Jaskiran et al in 2007 in his series of 228 cases
and was found to be significant. Our study had 4 cases with palpable
gallbladder and was found to be associated with 36.4% of difficult
cases. None with a palpable gallbladder had an easy outcome and the
factor was found to be significant( p 0.001)
SONOLOGICAL FEATURES
Preoperative ultrasound has been studied worldwide in
multivarious studies and has been found to have a significant
contribution. Thickness of gallbladder wall > 4mm, presence of fluid
around gallbladder and impacted stones were studied. Out of them,
thickened gallbladder wall was found to be significant as supported by
evidence from Fried et al and Nuri et al in 1994 and 2000 respectively.
A meta-analysis of certain diagnostic characteristics of
ultrasonography, which was published in1994 [57, 58] has revealed a
sensitivity and specificity of 94% and 78% respectively. Nachnani et al
and Supe et al in 2005 had identified the significant predictors of
conversion to be male gender, body mass index> 30, past history of
acute cholecystitis and Gall bladder wall thickness>4mm [58].
The role of pericholecystic fluid and impacted stone could not be
evaluated since the study was conducted in an elective setting and not
many patients presented to us with the above mentioned features.
Two cases turned out to be difficult, with one requiring
conversion without reaching scores greater than 10. Hence it is the
combination of factors and the clinical judgement that is important
rather than the actual score.
LIMITATIONS
A small number of patients included in the study.
Only elective cases are studied.
Anatomical variations not encountered and hence their influence
not validated.
Effect of comorbidities on the outcome not studied.
Cases that required conversion did not match with very high score
( greater than 10).
The influence of common bile duct stones and dilated duct on
predicting difficulty not evaluated, which have been found to
significant in certain studies.
CONCLUSION
As laparoscopic cholecystectomy has been widely accepted as the
gold standard for the management of gallstone disease, one has to have
adequate expertise in the same, as well as in the open approach so as to
manage complications. From our study, it is evident that it is possible to
identify the risk factors preoperatively and in a cost effective way too.
Predicting preoperatively a difficult outcome is important for, any
untoward complications that might occur would overshadow all the
advantages of laparoscopic surgery and make it an unsafe option. This
prediction might as well avoid wasteful attempts at laparoscopic
approach. Risk stratification would ensure patient safety and safety of
the surgeon as well by avoiding litigation.
BIBLIOGRAPHY
1. Beal JM. Historical perspective of gall stone disease. Surg
Gynecol Obstet 1984; 158:81.
2. Utpal de: Evolution of cholecystectomy: A tribute to Carl August
Langenbuch. Indian Journal of Surgery, Vol. 66, No. 2, Mar-Apr,
2004, pp. 97-100
3. Shehadi WH. The biliary system through the ages.Int Surg
1979;64:63.
4. Michael J.Zinner, Stanley M.Ashley, Maingot’s Abdominal
Operations, 11th ed.,
5. Thomas W. Sadler PhD: Langman's Medical Embryology.
6. Charles J.Yeo: Shackelford’s Surgery Of The Alimentary Tract,
6th edition
7. Skandalakis JE, Gray SW, Rowe Jr JS: Biliarytract.
In: Skandalakis JE, Gray SW, ed. Anatomical Complications in
General Surgery, New York: McGraw-Hill; 1983:31.
8. Rock J, Swan KG, Diego J: Calot's triangle revisited. Surg
Gynecol Obstet 1981; 153:410.
9. Benson E, Page RE: A practical reappraisal of the anatomy of the
extrahepatic bile ducts and arteries. Br J Surg 1976; 63:853.
10. Scott-Conner CEH, Hall T: Variant arterial anatomy in
laparoscopic cholecystectomy. Am J Surg 1992; 163:590
11. Niebergall-Roth E, Teyssen S, Singer MV:Neurohormonal
controlof gallbladder motility. Scand J Gastroenterol
1997; 32:737
12. Svenberg T, Christofides ND, Fitzpatrick ML, etal: Interdigestive
biliary output in man: Relationship to fluctuations in plasma
motilin and effect of atropine. Gut 1982; 23:1024.
13. Klein A, Lillemoe K, Yeo C, Pitt HA: Liver, biliary tract, and
pancreas. In: O'Leary J, ed. Physiologic Basis of Surgery,
Baltimore: Wilkins & Wilkins; 1996:441-478.
14. Tandon RK. Prevalence and type of biliary stones in India. World
J Gastroentero,2000;6(suppl3):4-5
15. Eun-HyungYoo, Soo-YounLee:The prevalence and risk factors
for gallstone diseaseClinical Chemistry and Laboratory
Medicine. Volume 47, Issue 7, Pages 795–807, June 2009
16. Nakeeb A, Comuzzie AG, Martin L, et al: Gallstones: Genetics
versus environment. Ann Surg 235:842, 2002.
17. G.L. Gill, W.H. Mair, J.C. Goligher: Gallstones after ileostomy
and ileal resection. Gut 1975;16:932-936
18.. Admirand WH, Small DM. The physicochemical basis of
cholesterol gallstone formation in man. J Clin
Invest. 1968;47:1043–1052
19. Strasberg SM: The pathogenesis of cholesterol gallstones a
review. J Gastrointest Surg 2:109, 1998
20. Holzbach RT: Recent progress in understanding cholesterol
crystal nucleation as a precursor to human gallstone formation.
Hepatology 1986; 6:1403-1410.
21. Holzer A, Harsch S, Renner O, Strohmeyer A, Schimmel S,
Wehkamp J, Fritz P, Stange EF. Diminished expression of apical
sodium-dependent bile acid transporter in gallstone disease is
independent of ileal inflammation.Digestion. 2008;78(1):52-9.
22. Attili AF, De Santis A, Capri R, et al: The natural history of
gallstones: The GREPCO experience. The GREPCO
Group.Hepatology 21:655, 1995.
23. MD Gary D. Friedman Natural history of asymptomatic and
symptomatic gallstones The American Journal of SurgeryVolume
165, Issue 4, April 1993, Pages 399–404
24. Strasberg SM: Cholelithiasis and acute cholecystitis. Baillieres
Clin Gastroenterol11:643, 1997.
25. Lo CM, Liu CL, Lai EC, et al: Prospective randomized study of
early versus delayed laparoscopic cholecystectomy for acute
cholecystitis. Ann Surg 1998; 227:461-464.
26. Rutledge D, Jones D, Rege R, et al: Consequences of delay in
surgical treatment of biliary disease. Am J Surg 2000; 180:
466-469.
27. Uchiyama K, Onishi H, Tani M, et al: Timing of cholecystectomy
for acute cholecystitis with cholecystolithiasis.
Hepatogastroenterology 2004; 51:346-348.
28. Boboev BD. [Ultrasonography in the diagnosis of cholelithiasis
and its complications]. VestnKhirIm I IGrek. 2012;171(2):21-4.
29. Jansen S, Jorgensen J, Caplehorn J, Hunt D, Preoperative
ultrasound to predict conversion in laparoscopic cholecystectomy:
Surg LaparoscEndosc. 1997 Apr;7(2):121-3.
30. Lee HJ, Choi BI, Han JK, et al: Three-dimensional
ultrasonography using the minimum transparent mode in
obstructive biliary diseases: Early experience. J Ultrasound Med
21:443, 2002.
31. Ralls PW, Jeffrey RB Jr., Kane RA, et al: Ultrasonography.
Gastroenterol Clin North Am 31:801, 2002.
32. Wexler RS, Greene GS, Scott M: Left hepatic and common
hepatic ductal bile leaks demonstrated by Tc-99m HIDA scan and
percutaneous transhepaticcholangiogram. Clin Nucl Med 19:59,
1994.
33. Liu TH, Consorti ET, Kawashima A, et al: Patient evaluation
and management with selective use of magnetic
resonance cholangiography and endoscopic retrograde
cholangiopancreatography before laparoscopic cholecystectomy.
Ann Surg 234:33, 2001.
34. David R. Fletcher, Michael S.T. Hobbs,Complications of
Cholecystectomy: Risks of theLaparoscopic Approach and
Protective Effects of Operative Cholangiograph- A Population-
Based Study, ANNALS OF SURGERYVol. 229, No. 4,
449-457.
35. Roslyn JJ, Binns GS, Hughes EX, et al: Open cholecystectomy:
A contemporary analysis of 42,474 patients. Ann Surg
1993; 218:219-229.
36. Chen AY, Daley J, Pappas TN, et al: Growing use of
laparoscopic cholecystectomy in the national Veterans Affairs
Surgical Risk Study: Effect on volume, patient selection, and
selected outcomes. Ann Surg 1998; 227:12-24.
37. Jatzko G, Lisborg PH, Perti AM, et al. Multivariate comparison
of complications after laparoscopic cholecystomy and open
cholecystectomy. Arm Surg. 1995;221:381–6.
38. S.Duca, OBãlã, N Al-Hajjar, C lancu, IC Puia, D
Munteanu, and F Graur:Laparoscopic cholecystectomy: incidents
and complications. A retrospective analysis of 9542 consecutive
laparoscopic operations, HPB (Oxford). 2003; 5(3): 152–158
39. Vikas Gupta, NisarChowdri, Nazir Ahmad Wani,SameerNaqash:
LAP V/S Open Cholecystectomy:A Prospective Study of 800
Patients,www.jkscience.org Vol. 11 No. 1, January-March 2009
40. J.BuenoLledó, M.PlanellsRoig, C.ArnauBertomeu et
al.,Outpatient laparoscopic cholecystectomy. A new gold standard
forcholecystectomyREV ESP ENFERM DIG (Madrid)Vol. 98.
No.1, pp. 14-24, 2006
41. Forrest Calland, MD, Koji Tanaka, BA, Eugene Foley, Outpatient
laparoscopic cholecystectomy: Implementation of a clinical
pathway Ann Surg. 2001 May; 233(5): 704–715
42. Voyles CR, Berch BR. Selection criteria for laparoscopic
cholecystectomyin an ambulatory care setting. Surg Endosc 1997;
11: 1145-6.
43. Novitsky YW, Kercher KW, Czerniach DR, Kaban GK, Khera S,
Gallagher-Dorval KA, Callery MP, Litwin DE, Kelly JJ:
Advantages of mini-laparoscopic vs conventional laparoscopic
cholecystectomy: results of a prospective randomized trial. Arch
Surg. 2005 Dec;140(12):1178-83.
44. Barkun JS, Barkun AN, Sampalis JS, et al. Randomized
controlled trial of laparoscopic versus mini-
choleRobertsKcystectomy. Lancet 1992;340
45. Marks JM, Phillips MS, Tacchino et al., Single-incision
laparoscopic cholecystectomy is associated with improved
cosmesis scoring at the cost of significantly higher hernia rates:
1-year results of a prospective randomized, multicenter, single-
blinded trial of traditional multiport laparoscopic
cholecystectomy vs single-incision laparoscopic
cholecystectomy.J Am Coll Surg. 2013 Jun;216(6):1037-47
46. Sohn BS, Kim SR, Park IY, Kim EJTransvaginal laparoscopic
cholecystectomy (hybrid NOTES cholecystectomy).
J LaparoendoscAdv Surg Tech A. 2010 Apr;20(3):245-7.
47. Lucian Panait, MD, Stephanie G Wood, MD, Robert L Bell, MD,
Andrew J Duffy, MD, Kurt E Roberts,Transvaginal Notes
Cholecystectomy: Key Technical Points, Society of American
Gastrointestinal and Endo Surgeons.
48. Alponat A, Kum CK, Koh BC, et al. Predictive factors for
conversionof laparoscopy Cholecystectomy.World J Surg 1997;
21: 629-33
49. Wiebke EA, Pruitt AL, Howard TJ et al. Conversion of
laparoscopicto open Cholecystectomy. An analysis of risk
factors.Surg Endosc1996; 10: 742-5.
50. Michael R, Fred B, Ponsky J. Predictive factors for conversion
oflaparoscopic Cholecystectomy. Amer.J Surg 2002; 184(3):
254-8.
51. Rosen M, Brody F, Ponsky. J Predictive factors for conversion of
laparoscopic cholecystectomy.Am J Surg. 2002 Sep;184(3):
254-8.
52. Fried GM, Barkun JS, Sigman HH, Joseph L, Clas D, Garzon
J, Hinchey EJ, Meakins JL. Factors determining conversion to
laparotomy in patients undergoing laparoscopic
cholecystectomy.Am J Surg. 1994 Jan;167(1):35-9; discussion
39-41
53. Gabriel R, Kumar S, Shrestha A: Evaluation of predictive factors
for conversion of laparoscopic cholecystectomy, Kathmandu
University Medical Journal (2009) Vol 7, No.1, Issue 25, 26-30.
54. Jaskiran S. Randhawa. Aswini K. PujahariPreoperative prediction
of diffi cult lap chole: a scoring method 198 Indian
J Surg (July–August 2009) 71:198–201
55. Nuri et al.A risk score for conversion from laparoscopic to open
cholecystectomy The AmericanJournal of Surgery
Volume 181, Issue 6, Pages 520-525, June 2001
56. Simopoulos, Botaitis, Polychronidis:Laparoscopic
cholecystectomy in obese patients.Obes Surg ( 2005)
57. Nachnani J, Supe A: Pre-operative prediction of difficult
laparoscopic cholecystectomy using clinical and ultrasonographic
parameters.Indian J Gastroenterol 2005, 24:16-8.
58. Jansen S, Jorgensen J, Caplehorn J, Hunt D: Preoperative
ultrasound to predict conversion in laparoscopic
cholecystectomy.Surg LaparoscEndosc 1997, 7(2):121-3
59. C. Simopoulos, Botaitis, A.Polychronidis: Risk factors for
conversion of laparoscopic cholecystectomy, Surg Endosc (2005)
19;905-909.
60. Tayeb M, Raza SA, Khan M R, Azami R. Conversion from
laparoscopic to open cholecystectomy: Multivariate analysis of
preoperative risk factors. J Postgrad Med 2005;51:17-20
PROFORMA
SL. NO:
NAME : AGE /SEX: IP NO:
ADDRESS WITH CONTACT NUMBER:
DATE OF ADMISSION: DATE OF DISCHARGE/ DEATH:
HISTORY OF PRESENTING ILLNESS:
H/O abdomen pain- onset
duration
progression
radiation
aggravating/relieving factors
H/O dyspepsia
H/O nausea/vomiting
H/O abd.distension
H/O fever, jaundice, pruritus
H/O high colored urine , clay colored stools.
PAST HISTORY:
H/O Diabetes mellitus/hypertension/asthma/TB/epilepsy/cardiac illness
H/o similar episodes in the past, if any:
H/o major illness/ hospital admissions, if any
PERSONAL HISTORY:
Whether a smoker or an alcohol consumer
FAMILY HISTORY:
TREATMENT HISTORY:
CLINICAL EXAMINATION:
General examination:
Systemic examination:
CVS
RS
CNS
Per abdomen
Clinical diagnosis:
INVESTIGATIONS:
Complete blood count
Random blood sugar
Renal function test: Blood urea, serum creatinine
Liver function test
Chest X ray, ECG
Ultrasonogram
FINAL DIAGNOSIS: